Is minimalism an option to manage plantar fasciitis?

More and more blog posts and articles are claiming that minimalist running is the best thing for the management of plantar fasciitis, most of which are from minimalist or barefoot runners who have no clinical experience actually treating the condition, yet seem to hold very strong clinical opinions (for example see this self-appointed expert). They may have had the condition themselves, but we do know that ineffective treatments sometimes work.

Minimalist and barefoot runners get plantar fasciitis and so do traditional running shoe wearers – just check around the barefoot and minimalist forums to see how many are asking for advice on it! Even those that promote minimalism have developed plantar fasciitis (see Pete Larsen & Once and Future Runner). If barefoot and minimalist runners get plantar fasciitis, then how can this be a solution for plantar fasciitis?

The reason most often cited as to why minimalism is the way to go for plantar fasciitis is not the evidence, but the belief that it is the best way to strengthen the muscles that is supposed to be needed to treat plantar fasciitis. As that “expert” says, “Strengthening the feet is critical for PF sufferers“. and as Mark Cucuzzella said, “the only way that you can actually fix plantar fasciitis is to address the root cause… weak foot muscles“. Are weak foot muscles really the cause of plantar fasciitis or do these people just wish it was the case? Wishful thinking is just another fallacy and does not make it true.

Those who want to promote minimalism for plantar fasciitis need to come up with some evidence that supports them and answer these questions:

  • What actual evidence do you have for it? (especially in the context of the strength of the evidence for other treatment options for plantar fasciitis).
  • Why have none of the risk factors studies on plantar fasciitis identified muscle weakness as a problem? In all the scientific literature on plantar fasciitis, muscle strength never even gets mentioned, let alone considered as an issue. (I did some ad hoc testing of muscle strength using a reliable and valid device that measures toe plantar flexion strength in 6 people with unilateral plantar fasciitis and could not find a muscle strength deficit on the plantar fasciitis side. I am the first to admit that this was no scientific study, but if muscle strength was an issue, don’t you think that this testing would have shown it?).
  • As discussed here, barefoot or minimalism have not been shown to make the intrinsic muscles of the foot stronger anyway.
  • Why is it that most clinicians who treat a lot of plantar fasciitis never think muscle strength is an issue? Why do the vast majority of plantar fasciitis cases get better without muscle strengthening? and without minimalism?
  • Why do minimalist and barefoot runners get plantar fasciitis (see above)?
  • Why does the typical non-runner with plantar fasciitis actually get more pain when they go barefoot? How can that be a good thing?
  • Why does the only randomized controlled study on this show minimalism is worse than staying in the shoes that they got the injury in (see below)?

What does the evidence say?
One study has looked at this:

Examining the degree of pain reduction using a multielement exercise model with a conventional training shoe versus an ultraflexible training shoe for treating plantar fasciitis.
Ryan M, Fraser S, McDonald K, Taunton J.
Phys Sportsmed. 2009 Dec;37(4):68-74.
Plantar fasciitis is a common injury to the plantar aponeurosis, manifesting as pain surrounding its proximal insertion at the medial calcaneal tubercle. Pain is typically worse in the morning when getting out of bed, and may subside after the tissue is sufficiently warmed up. For running-based athletes and individuals who spend prolonged periods of time on their feet at work, plantar fasciitis may become recalcitrant to conservative treatments such as ice, rest, and anti-inflammatory medication. Exercise-based therapies have received only limited attention in the literature for this common problem, yet they are becoming increasingly validated for pain relief and positive tissue remodeling at other sites of similar soft-tissue overuse injury. This study reports on pain outcomes in individuals experiencing chronic plantar fasciitis whiles wearing a shoe with an ultraflexible midsole (Nike Free 5.0) (FREE) versus a conventional training (CON) shoe in a 12-week multielement exercise regimen, and after a 6-month follow-up. Adults with >/= 6-month history of painful heel pain were recruited and randomly assigned to wear 1 of the 2 shoes. All subjects completed the same exercise protocol. A visual analogue scale item tracked peak pain in the preceding 24 hours taken at baseline, 6- and 12-week points, and at the 6-month follow-up. Twenty-one subjects completed the program (9 FREE; 12 CON). Both groups reported significant improvements in pain by the 6-month follow-up, and the FREE group reported an overall reduced level of pain throughout the study as a result of lower mean pain scores at the midpoint and post-test compared with the CON group. The exercise regimen employed in this study appears to reduce pain associated with chronic plantar fasciitis, and in doing so, the Nike 5.0 shoe may result in reductions in pain earlier than conventional running shoes.

This study compared two groups of runners with plantar fasciitis. One group continued to use their original shoes and the other group used minimalist shoes (Nike Free). The authors claimed the results found no statistical difference between the groups but there was a trend: “the Nike 5.0 shoe may result in reductions in pain earlier than conventional running shoes.” However, what was not reported in the abstract was the dropouts in the minimalist group due to their symptoms getting so bad, so they withdrew from the study. The gold standard for the analysis and presenting the results of randomized controlled trials is to use what is called the intention to treat analysis (as recommended by the CONSORT statement and every textbook on randomized controlled trials). This means that the pain scores of the dropouts in the minimalist group should have been factored into the analysis. So, in reality, this study actually showed that the minimalist group did worse. I have already previously done an analysis of this study here.

The evidence from this study is that if you use minimalist shoes, you are probably going to get a worse outcome compared to staying in the shoes you got the injury in (which a lot of people change anyway!). What is an ethical evidence based clinician supposed to do? Do what the evidence says or do what some bloggers with no clinical experience say they should do?

Minimalism for Plantar Fasciitis?
I do not think foot strike pattern or running form actually has anything to do with plantar fasciitis (it does for other injuries). That is not because I don’t want it to be (wishful thinking), it is what the above tells me. I have no problems if a runner wants to do minimalism running or go barefoot, just don’t do it expecting that it will fix plantar fasciitis. There may be some compelling reasons to take up minimalistic or barefoot running, but plantar fasciitis is not one of them. I have previously done a pretty poor attempt at a satire on this here, that got republished here.

Of course some runners with plantar fasciitis who transition to barefoot or minimalism will find their plantar fasciitis symptoms improve at the same time and the same could happen if you go the other way, but that is more likely to be due to a change in the natural history of the condition (see: Why Ineffective Treatments Sometimes Work). Those symptoms may have improved at the same time if they had not transitioned. That is why we have randomized controlled studies to avoid falling into the natural history or placebo effects trap.

As always, I go where the evidence takes me until convinced otherwise

POSTSCRIPT: I just read Scott Douglass’s The Runners World Complete Guide to Minimalism and Barefoot Running (a good book!) and it mentions that a dramatic increase in the plantar fascia’s workload can lead to an immediate injury. He is right and it will. However, it is suggested that minimalism increases this load. If this is the case then how can minimalism be a good thing for plantar fasciitis? (Add that to the list of dot point questions above!). Having said that I do not believe the load going through the plantar fasica is any different when shod (generally) or not. I am very familiar with all the research on the plantar fascia (and have two publications on it myself!) and there is nothing in that body of literature that indicates that the plantar fascia is subjected to any greater loads when forefoot striking….again, just another case of wishful thinking and statement making that the uninformed believe to be true (because they want it to be true!) without any reference to the evidence. I will soon do a post on the plantar fascia and the windlass mechanism as it does keep coming up.

¹Additionally that same “expert” talked about above tells his blog readers: “Do not stretch the arch/PF directly, as this may only create a cycle of “tear and repair”“. If you should not do that, then how about explaining why this randomized control trial shows that this is exactly what you should be doing? Can you see the dangers of those with strong opinions about clinical conditions yet with no clinical experience and no knowledge of the scientific evidence are if they are let loose in the blogsphere and not be held accountable for their advice? No wonder so many cases of plantar fasciitis become chronic due to following such advice.

Reference:
Ryan, M., Fraser, S., McDonald, K., & Taunton, J. (2009). Examining the Degree of Pain Reduction Using a Multielement Exercise Model with a Conventional Training Shoe Versus an Ultraflexible Training Shoe for Treating Plantar Fasciitis The Physician and Sportsmedicine, 37 (4), 68-74 DOI: 10.3810/psm.2009.12.1744

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29 Responses to Is minimalism an option to manage plantar fasciitis?

  1. Jim Hixson July 30, 2013 at 9:14 pm #

    This seems like another rearguard attempt to prevent a complete rout of the old school of thinking that claims that support of the foot is commonly required for it to be healthy. I would argue that external support is nothing more than treating the symptom, but not the underlying condition, which is exactly what Mark Cucuzzella wrote.

    Since it is a well-known fact (No, not wishful thinking or any other logical fallacy on your extensive list) that the body responds to the demands that are placed upon it (Specific Adaptation to Imposed Demands), it is nonsense to conclude that providing an external support (shoe, orthotic, walking boot, etc.) does not have a negative effect on the strength, flexibility, balance, and responsiveness of the foot. Certainly nobody would claim that externally supporting another part of the body, say the arm when it is broken, by wearing a cast or a splint allows the musculature around the elbow joint to maintain its strength and range of motion.

    Instead of having to list other criticisms of the results, methodology, and logic used by a small subset of influential podiatrists who have a tremendous stake in maintaining the status quo, would you simply answer these questions:

    1. Why are humans the only animals that need external support in order to function correctly during locomotion?
    2. Would there not be an evolutionary imperative for humans to be able to walk and run without external support?
    3. What are the positive effects of traditional footwear other than protecting the plantar surface from dangerous objects and extreme temperatures?
    4. Do you think that humans move naturally barefoot or do they require external support?
    5. Is natural movement preferable (!), or is it a good idea to wear a shoe that elevates the heel and changes the natural mechanics of the foot?

    Obviously these are all leading questions and the answers to these questions will overlap. You can clearly see that I’m wondering why the foot can’t function naturally and efficiently without being supported, stabilized, and cushioned. The default position of a healthy foot is one that is unsupported and I haven’t seen any argument to the contrary that is scientifically convincing.

    Unfortunately I think that many supporters of externally supporting the foot sound quite similar to defenders of other outmoded ways of thinking in that they seem to love citing studies that are sometimes so thoroughly flawed that they are worthless. Most of these individuals are podiatrists, not really true medical doctors and they have little contact with foot dysfunction when their view of the world is not suspended. Many of these individuals enforce their rules of logic so selectively and are so lacking in introspection that their results have even less value than selected anecdotes.

    While it’s true that some of these podiatrists have published articles, I’ll pull rank and state that I have a background in anatomy and kinesiology and have sold over 35,000 pairs of running shoes in the last 15 years and there is no doubt that when runners and walkers make a controlled transition to minimal shoes the strength and health of their feet improves dramatically. I also know many people who are barefoot, yet none of them have had plantar fasciitis, as long as they gradually created a strong functional base before making their final transition to their natural state, that is to say, barefoot.

    Because barefoot is the default/natural condition of the foot, I think that it is a case of wishful thinking when individuals claim that being barefoot or wearing minimal shoes is, well, unnatural. The burden of proof should clearly be on those individuals who claim that external support is preferable or necessary for the foot to function most efficiently and with the least chance of injury. Can you do this?

    • Craig Payne July 30, 2013 at 9:19 pm #

      So why do minimalist /barefoot runners get plantar fasciitis?
      Why does the only randomized trial on this show the minimalist runners did worse?

      No thanks; I will stick to what the evidence says.

      BTW; I just read this on your blog: “Although there is no evidence that suggests that a foot that affected by plantar fasciitis will become stronger if is externally supported by a stable shoe or orthotic
      What do you say about the recent study that showed muscles got stronger in motion control shoes? What about the two published studies that showed foot orthotics strengthened the muscles; and the one that showed they did not weaken them. Have you even read that research? Don’t you think you should be familiar with what the evidence says before you say that on your blog?

      ..and this: “there is evidence that individuals who habitually live barefoot or wear minimal shoes do not have plantar fasciitis. “. There is NO evidence that says that. You are making it up. What reference are you using for that, as I am curious what research you think shows that? …. and you accused me of ‘wishful thinking’! … don’t figure!

      Most of what you have written is good evidence as to why we need to rely on the evidence. You have fallen for many of the logical thought fallacies, such as the appeal to nature fallacy, the appeal to antiquity fallacy, etc. To avoid those fallacies as well as rhetoric and propaganda, we have to go back to what the scientific evidence says. Thanks for confirming that!

    • Kevin A. Kirby, DPM August 1, 2013 at 3:47 pm #

      Jim:

      I wasn’t going to bother responding to your nonsense until I read your following quote:

      “Most of these individuals are podiatrists, not really true medical doctors and they have little contact with foot dysfunction when their view of the world is not suspended. Many of these individuals enforce their rules of logic so selectively and are so lacking in introspection that their results have even less value than selected anecdotes.

      While it’s true that some of these podiatrists have published articles, I’ll pull rank and state that I have a background in anatomy and kinesiology and have sold over 35,000 pairs of running shoes in the last 15 years and there is no doubt that when runners and walkers make a controlled transition to minimal shoes the strength and health of their feet improves dramatically.”

      For your information, Jim, we podiatrists are considered doctors here in the USA. Podiatrists do perform foot and ankle surgery, we are on hospital medical staffs and sit on hospital boards and medical boards, we give injections, we repair fractures and other serious injuries in the foot and ankle, we see athletes and non-athletes with very serious and debilitating injuries, we prescribe medication and perform x-rays and fluoroscopy, we prescribe MRI, CT and bone scans, and many of us also publish scientific articles in peer-reviewed international journals and lecture nationally and internationally on foot biomechanics, shoe biomechanics and plantar fasciitis at large, multi-specialty seminars.

      Now, Jim, what are shoe salesmen, like yourself, who may have taken an undergraduate course in anatomy and biomechanics allowed to do herelegally in the USA?

      Can shoe salesmen make diagnoses? No.

      Can shoe salesmen treat people with surgery, injections and diagnose conditions by ordering x-rays, MRIs, CT scans, bone scans, bacterial and fungal cultures, blood tests and/or nerve conduction studies? No.

      Are shoe salesmen ever invited to lecture at major national and international seminars? I’ve never seen it in my 30 years of being a podiatrist.

      Do shoe salesman often overstate what they actually know just to impress a customer and make a shoe sale? Often.

      Can shoe salesmen legally do anything that even remotely resembles what a licensed health professional can do? No.

      In other words, having a shoe salesmen like yourself, who has never done surgery, made an accurate diagnosis, given an injection, ordered a diagnostic test and has only sold shoes come onto a forum such as this and say that podiatrists are “not true medical doctors”, to me, is quite entertaining. It also clearly demonstrates your ignorance of what the training of podiatrists actually is.

      Jim, it also curious that you seem to think that since “barefoot is the default/natural condition of the foot” that you make your living selling shoes when shoes certainly are not the “default/natural condition” of the foot. In fact, you state that you have sold 35,000 pairs of shoes which you yourself claim are unnatural and non-default conditions for the feet, but you still continue to make a living for yourself selling these unnatural items.

      Jim, the burden of proof should clearly be on those individuals like shoe salesmen, who, like yourself make a living claiming that external support to the feet, such as shoes, are necessary to make your customers’ feet function most efficiently and with the least chance of injury. Can you do this? Can you justify your existence as a shoe salesman that by you selling 35,000 pairs of external supports to the feet of your customers that these external supports were not just your way of making money off of your unsuspecting customers when you actually believe that they would be more “natural” and by being barefoot?

      In other words, why don’t you tell all the customers that enter your shoe store(s) that the items you sell are all unnatural and that they should forget about buying shoes at your store(s), return back to their natural and default state of being barefoot? Wouldn’t that be the most reasonable thing to do instead of continuing to make money off of your customers by selling external supports that you have no research justification for?

      Sincerely,

      Kevin A. Kirby, DPM, MS

      ***************************************************
      Kevin A. Kirby, DPM
      Adjunct Associate Professor
      Department of Applied Biomechanics
      California School of Podiatric Medicine

      Private Practice:
      107 Scripps Drive, Suite 200
      Sacramento, CA 95825 USA
      ***************************************************

    • Michigan Biomech August 1, 2013 at 7:34 pm #

      Ken

      You have perfectly demonstrated all the traits of why we need to rely on the scientific evidence rather than be blinded by nonsense from a fan boy. You are clearly blinded by an agenda that you either can’t read the scientific research or deliberately choose to ignore it. The whole idea of science is to avoid being hung up with the values of an agenda.

      The minimalism fad is over. The evidence is now showing that there is no advantage to it in terms of injury rates and metabolic efficiency. Consumers have lost interest in it and sales of minimalist shoes are dropping and the sales of motion control shoes are increasing.

      • Michigan Biomech August 1, 2013 at 7:41 pm #

        Forget to mention, I am not a podiatrist. Though I do not now what being a podiatrist has to do with this or not. Science is science!

        • Craig Payne August 1, 2013 at 7:44 pm #

          …and propaganda is propaganda; and rhetoric is rhetoric; and wishful thinking is wishful thinking!

          • Craig Payne August 1, 2013 at 9:20 pm #

            …and none of the research I refered to above was done by Podiatrists. And none of the “The evidence is now showing that there is no advantage to it in terms of injury rates and metabolic efficiency” was done by Podiatrists either … go figure! … but by Jim’s rationale and logic, is that the research is flawed without him even reading it!

  2. Ian Griffiths July 31, 2013 at 6:05 am #

    Jim,

    This has been said many times before but it seems it needs saying again. To compare shoes and/or foot orthoses to splints and braces is inappropriate and erroneous. Those that do so clearly have no understanding of the subject specific kinematic and kinetic efffects of shoes/orthoses, or instead are simply using false statements to drive their own agendas and sell something to the contrary. Which category do you fall in to? (Feel free to say both….)

    • Craig Payne July 31, 2013 at 7:42 pm #

      …which is why we need to rely on the scientific evidence rather that the nonsensical thought fallacies and the propaganda and rhetoric from the fan boi‘s

  3. Simon Bartold August 1, 2013 at 11:52 pm #

    I just wish people would understand where the “burden of proof’ lies. And clearly Jim Hixson does not.
    It also does him no credit to base his pseudo scientific argument and “pull rank”, and the basis that he has sold 35,000 pairs of shoes. This simply is not relevant.
    The discussion has become tiresome, because those people who are really thinking about this are not galvanised toward one side or other, Craig Payne being an example, but rather understand that this is about identifying individual circumstances for individual athletes, and making changes/recommendations accordingly.
    Jim’s comments are a classic example of “one tool in the tool box”, and whilst lighter, more flexible footwear obviously has its applications, using it as a treatment for plantar heel pain is unlikely to be beneficial.
    At the end of the day, having a clear understanding of the actual diagnosis.. which is unlikely to be “plantar fasciitis’ anyway, having the authority to order the appropriate examinations and tests, formulating a treatment program which will involve footwear somewhere along the way, having clear treatment goals and following up judiciously, is the way forward for anyone with plantar heel pain. This is what Dr. Kirby, and other sports medicine experts, podiatrists, physios, sports doctors, bring to the table.

    • Craig Payne August 2, 2013 at 12:04 am #

      …and don’t forget I do half my own running in minimalist shoes!

  4. Baturner August 2, 2013 at 7:25 pm #

    Thank you for the article. I have enjoyed reading the responses too. I would just like to relate an end user experince. My wife trained as a podiarist and given the issues I have personally had with my feet I feel i have an above average lay knowledge. I have suffered from plantar fasciitis for most of my life. I have tried almost every type of orthoic from leading local podiarist, my last podiarist had a phd in biomechantics. Sadly for me no conventional shoe and orthoic combo had any positive effect on my feet. So trying barefoot shoes was a no lose situation for me. It however horrified my wife. I would like to report (yes n-1) that for me barefoot shoes have been beneficial. I am not a runner. I am far too broken for that. But i now walk and sprint a little with out pain. I have slowly developed small arches and don’t exerince Morton nuroma any more. I wold add that an important aspect to my recovery, in my view was hiking on very rough steep hill tracks. I feel the combo of the barefoot shoes and the uneven surfaces strenghten my feet and legs. Once again thanks for the article.

  5. Sean August 6, 2013 at 10:35 am #

    Nike Frees are not a good example of true minimalist running. Re-do the experiment with actual bare feet and with Vibram 5 Fingers and Merrels.

    • Craig Payne August 9, 2013 at 6:36 pm #

      I not sure such a study would be ethical, given the concept of ‘prior plausibility’.

  6. I run August 8, 2013 at 8:00 am #

    Minimalism absolutely sucks for plantar fasciitis. I was stupid enough to listen to those crazies and paid for it by suffering from it for two years. Finally I went against them and tired the Hokas. Two weeks later, no pain and never looked back. Don’t listen to the crazies.

  7. I run too August 9, 2013 at 10:24 am #

    Well, horses for courses. I ran in Asics stability trainers for ten years no injuries. Many marathons, Ironman races, ultras. No injuries. I thought Hoka’s looked cool and gave them a try. 2 months later Plantar faciitis. Hoka’s are low drop, stiff, and have no stability. My advice is avoid them like the plague. (They were fun though 🙂 18 month struggle to get rid of it.

    • Craig Payne August 9, 2013 at 6:35 pm #

      Therein is the problem. Your anecdote is that the Hoka’s caused your plantar fasciitis and the post above says it fixed theirs. Do you think we should be making clinical decisions on the basis of anecdotes. Just because you had a negative experience with Hokas, everyone should avoid them like the plague? How do you explain their skyrocketing sales and all the positive anecdotes?

      It is exactly because of this we need to rely on the scientific evidence … that evidence says minimalism does not work for plantar fasciitis (despite anecdotes that it does and does not)

  8. Val T September 20, 2013 at 1:23 pm #

    I believe in the awesome supremacy of nature of making every human being different. I don’t think anyone can tell you exactly what is better for your foot when you are dealing with plantar fasciitis. I know people who have tried almost everything, even surgery, and still, not getting better. This is my case: I started running in the spring of 2010. I got fitted for shoes for overpronation at two local stores (I just wanted to have a second opinion). They both coincided that I needed shoes with a good arch support. So $125 dollars later there I was, off to train for my first 5K. A few months later I started to feel foot pain; if you ever had plantar fasciitis you know that “pain” is almost an understatement. I’m talking about getting up in the morning on my knees because of the stabbing pain on my heels. I went to the podiatrist who diagnosed me with PF, a few X-rays, fitting for orthotics, and almost $400 later (insurance included) I thought this would be the end of the nightmare. The truth is that everything I did, failed to make the PF better. Not even a bit. I dealt with the pain and the on and off training for 3 years. Yes, 3 years.
    My birthday is in March so as a birthday gift to myself I decided to get 2 pairs of minimalist shoes this spring, after trying the NB730 for a while but not for running. BOOM! Plantar pain started to shed away until having completely dissapear. After 3 painful years, when I thought that I was doomed to live with plantar pain all my life!
    Now, I know a couple of people at my gym who are dealing with PF. I tell them my story, but I don’t recommend them minimalist running because everyone is different and those people need to find whatever works for them.

    • Kevin A. Kirby, DPM September 20, 2013 at 3:33 pm #

      Val:

      Your anecdote is a good one.

      Let me give you another one. I have seen probably 20 patients in the last year that developed plantar fasciitis from either trying to run barefoot or from converting to minimalist running shoes on the advice of their friends, coaches or one of the ever decreasing number of vocal advocates of barefoot-minimalist shoe running.

      It is good you realize that everyone is different and treatments must be customized to each individual. I just wish that the rest of the barefoot-minimalist shoe evangelists also realized the same.

      Happy running.

      • Adam H SPT March 4, 2014 at 5:26 am #

        I have enjoyed reading this discussion and have one question regarding your thoughts on the minimalist shoes causing PF. Do you think a big cause of PF from people converting is an improper transition from a traditional (asics) shoe to a minimalist? The two are obviously quite different. I’m in PT school and we have talked about how human feet have evolved to depend more on external support during ambulation so to speak. Our intrinsic musculature is “weaker”, therefore, in need for additional support during our gait cycle. If we can in fact improve intrinsic strength by switching to a more “naturalistic” shoe, maybe it’s not the shoe, but rather the transition (too quick/rapid) is what’s causing all of the issues. For example with orthotics. In general, people who are issued orthotics shouldn’t wear them all day the first day they receive them, rather they should wear them an hour or two and slowly increase the usage until the patient’s foot accommodates for the orthotic improving the overall stability of the foot. With minimal knowledge of the subject I seek your thoughts and comments… Thanks!

  9. Larry Weisenthal May 1, 2014 at 6:52 pm #

    I don’t think that there is a universal truth relating to plantar fasciitis vis a vis minimalist shoes. I don’t think it’s at all inappropriate to suggest a trial of minimalist shoe wearing for plantar fasciitis, especially if this doesn’t respond well to other therapeutic approaches.

    My own prejudice is that at least some cases of plantar fasciitis are caused or exacerbated by long strides with extreme heel striking. If a runner switches from a conventional to a so-called minimalist shoe and continues to heel strike, I believe that this can and does predispose to further injury, including plantar fasciitis. Nike Frees, in particular, aren’t truly minimalist shoes, because they have padded heels which encourages long strides with heel strikes.

    One advantage of true barefoot running is that it’s quite difficult to have a long stride and a heel strike. I do believe that at least some, if not most, cases of plantar fasciitis will respond to a shorter shuffle stride and a flat footed or slightly ball to heel landing. Of course, any biomechanical adjustment, including running stride, should be done gradually and incrementally, allowing for muscular adaptation.

    I don’t think that one size fits all clinical trials addressing simplistic issues are all that helpful, in a situation like this. In the case of, for example, post-operative adjuvant chemotherapy of breast cancer, it’s crucial to identify what works best, and what works most often. This is a life or death situation, where the patient doesn’t get a second chance. But with plantar fasciitis, it’s very simple for patients to do clinical trials on themselves, with an “n of 1.”

    Try something. Try and do it properly. Don’t just look for a magic bullet (i.e. buying Nike Frees and believing that this is the entire answer to the problem) when, if the approach being pursued is that of minimalist footwear, one might be better off without a padded heel and with a diligent effort to gradually alter biomechanics, while monitoring for improvement or worsening of symptoms.

    If there is one thing with is entirely obvious, it is that feet do not come in one size and shape. It’s silly to quarrel that any particular footwear or any particular biomechanical adjustment is optimum for everyone. I am not a board certified podiatrist, but, after a lifetime of living with and running on my own feet, I am truly the world’s expert on these feet. I’m fully qualified to do self-experimentation on these feet to determine, for myself, what works the best for me. Everyone else has similar qualifications.

    My own testimonial is that I read “Born to Run” and it literally changed my life. But I’m only an “n of 1.”

    – Larry Weisenthal/Huntington Beach CA

  10. I hate shoes July 22, 2014 at 9:35 pm #

    Wow, for anyone like Jim who chooses to debate the pros of minimalist living including cruring PF, you are definatly in the lions den!! I am not going to try to convince anyone that shoes and supports are better or worse for PF, I only know what worked for me. I have been suffering from PF for about 4 years after living in combat boots for multiple deployments fighting those crazy wars in the Middle East. I noticed that going barefoot gave me releif and after trying just about everything except surgry and injections, I decided to lose the shoes. Now I know this is about a “minimalist” debate, but you have to be careful how you define any shoe a “minimalist shoe” (most say no greater than a 5mm drop). Although there are varying definitions within the shoe industry that qualifies a shoe to be truely minimalist, nothing can come close to the human foot. I have come across many barefoot enthusists in my quest to research this subject and many say they don’t like minimalist shoes because they can’t fully mimic the machanics of barefoot walking and running. Most dont wear anything with a rubber sole, even Vibam 5 fingers. They wear moccacins and other shoes made of leather instead of rubber soles. I think when debating wich is the best treatment for PF, one more variable needs to be considered; one who lives a true barefoot lifestyle. I don’t think there are enough people in western society that goes barefoot throught the year to conduct an accruate study, but what about other groups of people around the world who never wears shoes? How about people of East Africa like Kenya and Ethiopia? I have read many reports that suggest that these people don’t suffer from foot abnormalities suchs a PF. From the time they learn to walk they develope the running skills necessary to run efficiently and safley unlike children of the United States who strap on shoes as soon as they learn to walk. In all the forums I have read on whats best for the treatment of PF, I did not see any debate comparing shoes to a true barefoot walker or runner in reguards to treating PF. I wear my 5 fingers everywhere including in the house but I still feel heel pain. what is interesting is that when I go completly barefoot my pain completly goes away. why is this? Is it because when I stand in my 5 fingers, I shift too much weight on my heels like most people do in regular shoes? Could it be the shape of the Vibram sole that causes extra strech of my arch pulling the plantar Fascia away from the heel bone? I have read that most people stand wrong (too much weight on heels) and also don’t walk correct, using poor mechanics including improper running styles. Is this from wearing a well cusioned heel that is elevated, with a narrow elevated toe box found in the modern shoe? I don’t really know whether conventional shoes are the root cause of PF, or if minimalist shoes are any better at prevention or cure. I do know that anything strapped on your feet is not natrual although the minimalist shoe is the next best thing to going barefoot if you have no choice. since I kicked off my shoes for the past 3 months, my PF has been getting better with regular Icing, stretching, and rolling a golf ball under my foot 3 times a day. If I am out of my vibrams, I am virtually pain free (I did not achieve this level of success with traditional methods including supports in my shoes). In shoes, I suffered from fluid retention in my ankles and feet, varacose veins in my feet, and a narrow toe formation with toes pointing to the center (shape of a cowboy boot) Now, my feet are healthy and strong with better balance and circulation. In my experience, I feel that shoes and boots where the root cause of my PF, and the other foot problems I discussed. Now that I got rid of the traditional shoe, my toes are spreading out, and I have improved circulation with no swelling or varicose veins. In my opinion, although there is no universal treatment for PF, one thing is for certain, the traditional shoe is bad for the feet and may be the root cause of many of the foot problems we see in the U.S. including PF. Oh, and before I end my long, boring, and unorganized rant, I want to say one more thing… Mr. Kirby, why don’t podiatrist, like yourself, speak out against wearing modern shoes? You have to know that shoes are not good for the foot (generally speaking). I know that in some instances, certain shoes and orthotics are great treatment options for people born with abnormal gaits and other abnormalities that cause foot disfuctions. There are a few podiatrist who are voicing their opinion against modern shoes, but the rest of the pack are reluctant to jump on board.

    • Craig Payne July 22, 2014 at 9:38 pm #

      So how then do you explain the plantar fasciitis that develops in those who are barefoot/minimal running?

    • Kevin A. Kirby, DPM July 24, 2014 at 3:47 am #

      Since when have “modern shoes” been implicated in causing all foot pathologies? Do you have any evidence that modern shoes are the cause of all foot pathologies, or is that just something you are repeating after reading the semi-fiction novel “Born to Run”, or by believing everything that the minimalist/barefoot running zealots say in their barefoot/minimalist shoe/anti-rearfoot striking/back to nature blogs.

      For your information, I do often speak out against women’s shoe styles even though I know it often falls on deaf ears. For example, here is an article I wrote a few years ago for one of the national podiatry magazines.

      http://www.podiatrytoday.com/tales-from-the-frontlines-of-daily-shoe-battles

      Please provide me with scientific references which shows that “modern shoes” are the cause of foot pathologies or that “shoes are not good for the foot”. I guess you suppose that our modern military should not be wearing modern boots when going into battle but, rather, should be more natural and go either into battle barefoot or wearing huaraches?

      Dr. Kirby

  11. Imke September 16, 2014 at 8:19 am #

    I appreciate the discussion above, especially the part about the PF being an injury happening to people with their individual anatomy, experience, training regimen, shoe choice and so on.

    I’ve just gotten PF.
    My story in short:
    Started running in 2006, running injuryfree, doing two marathons, continued with triathlons from sprint to full Ironman distance in 2010, then doing half ironmans until this year.
    Walking the dog daily in the woods and (beautiful but steep Norwegian) mountains.

    Used quite “normal” shoes, both for overpronation and neutral.
    Both Nike, ASICS, New Balance, K-Swiss.
    No overuse injuries.
    At home, I walk around barefoot/without shoes a lot.
    I walk a lot on uneven trails, in trail running shoes.
    Started doing strength training with heavy loads this spring while cutting down in running.

    ==> went hiking for five days in the mountains (=40miles) with a medium heavy backpack (appr.20lbs) on stiff and uncushioned hiking boots (did the same for two years ago – all fine).

    After two days, terrible pain in my right heel and also below my toes and forfoot.
    But – pain is something normal when hiking and doing unusual activities, right?

    I hadn’t heard of PF then.
    Continued hiking, with more cushioned inner soles.
    The pain never went away.

    That is three weeks ago.
    I did some more hiking (steep mountain, 3000ft ascent), and that was where I realized that pain is not normal.

    I suspected PF, called my physiotherapist (“So – what to do now?”), discussed the issue and got it diagnosed by my doctor yesterday.

    My point is that I have been reading articles, blogs, A&P books for the last few days, only to found out that there is no consensus on treatment of PF.

    I can console myself that my version of PF came suddenly, as an acute form of overuse injury, which has now become subchronic.

    I’m thinking that we all get our injuries from what we do, and there is rarely only one cause for it.
    As for me, I had been eating very poorly, being exhausted and tired already before my hiking trip, so my body was simply to weak to bear the weight of myself (I weigh 125lbs) pluss the backpack, my boots were stiff and hard to walk in, I was tired all the time, my previous weight lifting (squats, deadlifts, basic exercises) doing shoeless must have put some additional strain on my foot –
    I guess all that has to be taken into account.

    I don’t think one super shoe, minimalist or super cushioned will do the trick.
    But I’m considering cushioned shoes (like Hoka One One) to walk on my feet with less pain and strain (I have a pair of Massai BT shoes, tried them for walking the dog, they were ok).

    I’m thinking that I ahve to deal with and remove/improve the complex factors leading to my PF.
    But I also have to think about the damage that is done to my foot.

    How do I make my plantar fascia/aponeurosis heel in the best possible way?
    “Fortunately” most of the pain is in my right foot
    The left foot is actually painfree (if not palpated on the right places by a doctor with strong pressure).

    What I cannot believe is, what I read on most blogs about continued running with PF.
    If it’s an injury, it should heal, right?
    I mean, it is important to use your feet to obtain sufficient blood circulation to transport away waste and support the healing process, but still, I think I’ll use a more conservative approach to injury heeling: rest. And rest. Gentle massage and stretching of the structures around (not the fascia itself).
    Walk as little as possible, take the bike instead of walking.
    I’ll start swimming.

    I’m just thinking that when I had a grad I MCL injury this winter, I was walking on crutches until painfree (=several weeks).

    If the PF consists of those micro tears, why should I be provoking more tears/scar tissue by using my foot?

    These are just some thoughts of mine.
    I’m open to every approach, but I think there is no “one size fits all” approach to PF.

    Treat the injury according to its causes, although those might be hard to find at first.
    Train alternatively (I’m looking forward to our local pool opening again this fall – swimming should be ok, right?).

    Now I’ll have closer look at your other articles before plunging into my anatomy and physiology books 🙂

  12. Christopher January 2, 2015 at 6:17 am #

    I’m not sure I trust either end of the debate from a research perspective. While I’m not a PhD in the sciences, I’ve obtained an advanced degree founded in quantitative and qualitative research and practice and am able to call out some red herrings in research designs.

    As a sufferer of various knee, ankle, and foot injuries, I try to inform myself the best I can as a patient and as a consumer of the medical industrial complex (I’ll spare a rant on that topic). Over the course of my research, I’ve noted that published discourse is myopic in addressing potential hidden variables in research design. Design issues I’ve noted is that they can be incredibly time limited, don’t factor for ranging life factors or practices, don’t address the bias of those being tested, focus in on a very specific homogeneous population, and/or have tiny sample sizes that may not be generalizable.

    I think we need a different control to address this debate from an alternative perspective. A quick and dirty design concept (thinking out loud) would be a longitudinal study that compares injury of those who are shod (all one’s life) vs. non-shod (all one’s life). After we have a fairer and more robust means of comparison and contrasts, we can have a more balanced discussion and means to improve the body of study.

    My two highly speculative cents: I venture that the relative comparison group for non-shods would results in a much lower incidence of injury. I think this is so based upon our success as a species. Humans have lived thousands of years without shoes. I don’t imagine we would be where we are today on the food chain if our feet need to be housed in $150 shoes and $500 orthotics to function correctly. I can myself provide many counterpoints to this; but this is what my gut tells me so I’m sticking to it until informed otherwise 😉

    • Kevin A. Kirby, DPM January 3, 2015 at 4:27 pm #

      Using your logic:

      “We, as a species, would have much longer lives without using antibiotics to treat infections since humans lived for thousands of years without antibiotics. I don’t image we would be where we are today on the food chain if our bodies needed antibiotics to function correctly.”

      We’ve been through all this before. Shoes have been used for at least 40,000 years by our ancestors (Trinkaus E: Anatomical evidence for the antiquity of human footwear use. J Arch Sci, 32:1515-1526, 2005). We humans choose to walk, run and play in shoes because we want to. The latest barefoot running fad produced many, many injuries all because some ill-informed individuals thought that running barefoot was more “natural” and thought that because it was more “natural” it was, of course, better. Well, women dying after child birth was more “natural” 10,000 years ago than it was today. Does that then also make mothers dying at an early age better also?

  13. Fat Guy Running June 25, 2015 at 7:06 pm #

    I too find it hard to believe either side. On one side you have the marketing departments for minimalist shoes and folks that are anti doctors, but on the other side you have a medical community that in large (not all though) are pill and medical procedure pushers.

    Here is my story: I’m a morbidly obese man (BMI of 46%) I currently weigh 340lbs. HOWEVER 10 years ago I was 240 and started running. Back then I wore regular old running shoes (NB / NIKE). I suffered from shin splints SO bad that I gave up running and only got fatter (made it to the 300+lbs range).

    FIVE years ago (still in the 300lbs range) I decided to start running again and SLOWLY started training with Five Fingers. for the first week only 5 minutes total. Second week 10. So on so forth. Eventually I was doing 5ks! Even 10ks! Granted I was almost the last person to cross the finish line, but I did it! Pretty good for a 300+lbs man. And I NEVER had foot or Achilles pain! I would have tired legs, calves, etc, but no foot pain.

    Then just this past year I started doing crossfit. A lot of kettlebells, stepups, situps, jump ropes, jumping jacks, etc. About 2 months ago the PF pain started. I Googled to my death about different treatments. I have the Strassburg sock, multiple balls to roll on my foot (golf, lacrosse, spikey balls), nightly ice buckets, special creams. Some help but are only temporary until the next time I workout. The only thing that seems to fix it is rest.

    So again, like many other people, it’s in conclusive. Minimalist shoes like the VFF made it possible for me to run properly (fore foot strike) and run pain free (no shin splints) for about 2 years. However now crossfit has found a hole that the minimalist shoe can’t fill.

    In the end I’m going to my podiatrist today and I hope that he’s open to giving me his opinion with what I tell him.

  14. markjohnconley April 22, 2016 at 9:16 am #

    Stopped reading the first contributor’s post when I read, “support of the foot ” ………

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